Firstenberg, Michael S.

Sai-Sudhakar, Chittoor B.

Sun, Benjamin

Elsevier - Publisher Connector 

Biventricular mechanical assist for complex, acute post-infarction ventricular septal defect 

such cases. Accurate diagnosis and hemodynamic assessments by
cardiac catheterization were necessary before surgical repair. Surgical
repair was successfully done by division of the anomalous PV without
cardiopulmonary bypass. Our case showed the possibility of coexist-
ence of normal and anomalous PVs in the common situation of
PAPVC of the right upper PV. Surgeons must keep in mind this rare
anomaly and its repair.
Conclusion
We reported surgical repair of PAPVC of the right upper PV,
which connected both to the SVC and to the LA, showing retro-
grade blood flow from the LA to the SVC.
References
1. Bahnson HT, Spencer FC, Neill CA. Surgical treatment of thirty-five
cases of drainage of pulmonary veins to the right side of the heart.
J Thorac Surg. 1958;36:777-9.
2. Lewis FJ. High defects of the atrium. J Thorac Cardiovasc Surg.
1958;36:1-5.
3. Swan HJ, Kirklin JW, Becu LM, Wood EH. Anomalous connection of
right pulmonary veins to superior vena cava with intra-atrial commu-
nications: hemodynamic data in eight cases. Circulation. 1957;16:54-
66.
4. Beck C, Wessel A, Yelbuz TM, Bertram H. Unusual case of anomalous
pulmonary venous return with left atrial to systemic venous shunt.
Circulation. 2006;113:e840-1.
Biventricular mechanical assist for complex, acute post-infarction
ventricular septal defect
Chittoor B. Sai-Sudhakar, MBBS, FRCS, Michael S. Firstenberg, MD, and Benjamin Sun, MD, Columbus, Ohio
Post-infarction ventricular septal defects (PI-VSDs) rep-resent a catastrophic complication after acute myocardialinfarctions. Despite advances in surgical and postopera-tive management, operative mortality is still 10% to
60%.1 Furthermore, little has been written describing the options
in managing the severe and often biventricular failure that is
associated with PI-VSD and that is a significant factor influencing
postoperative morbidity and mortality. We describe a patient with
complex PI-VSD who, despite appropriate and prompt surgical
management, required biventricular mechanical assist devices
(biVADs) as a bridge to recovery.
Case Report
A 53-year-old man was admitted to an outside hospital with vague
abdominal symptoms and a presumed diagnosis of acute chole-
cystitis. Severe hypotension and a new murmur shortly developed.
Echocardiography revealed a large posteroinferior PI-VSD. After
the patient was urgently transferred to our medical center, cardiac
catheterization revealed a complete right coronary artery occlusion
with critical left anterior descending coronary artery and ramus
diseases. Because the patient was in profound cardiogenic shock
requiring multiple high-dose pressors and intraaortic counter pul-
sation, he was taken urgently to the operating room. Intraopera-
tively, the patient’s heart was diffusely erythematous, and there
was a large inferior wall infarct, an akinetic right ventricle, and
severe mitral regurgitation from a ruptured papillary muscle.
Transesophageal echocardiology demonstrated a 4  4-cm pos-
teroinferior VSD extending to the annulus of the mitral valve.
After standard bicaval cannulation, cardiopulmonary bypass, and
antegrade and retrograde cardioplegic arrest, an incision was made
parallel to the posterior descending artery. The defect was closed
with a large bovine pericardial patch with pledgeted sutures
through healthy-appearing tissue. Coronary artery bypass grafting
was performed in the diseased vessels. A mechanical mitral valve
was inserted using standard techniques. Secondary to severe intra-
operative right ventricular failure, a right ventricular assist device
(Abiomed 5000, Abiomed Inc, Danvers, Mass) was placed. How-
ever, with increasing right ventricular assist device flows, left to
right shunting across a residual VSD increased. Because of the
perceived technical and physiologic difficulties associated with
attempts at closure, combined with worsening left ventricular
function, a left ventricular assist device (Abiomed 5000) was
placed. The patient was stabilized and weaned from bypass. His
initial intensive care unit course was unremarkable as he was
rapidly extubated and weaned from pharmacologic support. After
several months of aggressive rehabilitation, the patient underwent
explantation of his biVAD and residual VSD closure. The patient
tolerated this procedure well, and after pharmacologic optimiza-
tion of his chronic heart failure he was transferred to an outpatient
rehabilitation facility. At 18 months post-infarction, the patient
was well.
Discussion
PI-VSDs complicate up to 0.02% of myocardial infarctions.2 De-
spite advances in the surgical care of these moribund patients,
operative mortality still approaches 50% with major risks, includ-
ing cardiogenic shock, renal failure, right and/or left ventricular
From the Department of Cardiothoracic Surgery, The Ohio State Univer-
sity, Columbus, Ohio.
Received for publication May 18, 2006; accepted for publication June 27,
2006.
Address for reprints: Michael S. Firstenberg, MD, Division of Cardiotho-
racic Surgery, N846 Doan Hall, 410 W. 10th Avenue, The Ohio State
University, Columbus, OH 43210 (E-mail: msfirst@gmail.com).
J Thorac Cardiovasc Surg 2006;132:1238-9
0022-5223/$32.00
Copyright © 2006 by The American Association for Thoracic Surgery
doi:10.1016/j.jtcvs.2006.06.037
Brief Communications
1238 The Journal of Thoracic and Cardiovascular Surgery ● November 2006
failure, size of VSD, posterior/inferior locations, and residual
VSD.3 Management consists of VSD closure, coronary artery
bypass grafting as needed, and aggressive postcardiotomy and
end-organ support. Residual shunts are found in up to 40% of
patients. Operative repair is associated with mortality greater than
60%,4 which has prompted interest in percutaneous closure, but
the role of these procedures is still undefined.5 In our case, the
implantation of a biVAD served as a bridge to recovery. By
minimizing associated postoperative end-organ damage with car-
diac support, we allowed for physiologic recovery so the residual
VSD could be successfully closed and the impact of the massive
myocardial infarction and associated heart failure could be mini-
mized. Limitations include the need for multiple procedures (ie,
device weaning/explant), aggressive anticoagulation in a high-risk
patient, and meticulous follow-up.
Right ventricular support is critical after the acute volume and
pressure overload of a PI-VSD. Recovery may be unpredictable and
prolonged, necessitating long-term biventricular support. Short-term
univentricular options, such as intraaortic balloon pumps, extracorpo-
real membrane oxygenation, or left ventricular assist devices, are
limited in right ventricle failure and residual shunting. A total
artificial heart precludes native cardiac recovery and obligates
transplantation; nevertheless, this may be an option with the ap-
propriate resources and experience.
Conclusion
Biventricular mechanical support, as demonstrated in this complex
case, should be considered a useful tool as a bridge to recovery in
patients with PI-VSDs.
References
1. Cummings RG, Califf R, Jones RN, Reimer KA, King YH, Lowe JE.
Correlates of survival in patients with postinfarction ventricular septal
defect. Ann Thorac Surg. 1989;47:824-30 (update: 1997;63:1508-9).
2. Crenshaw BS, Granger CB, Birnbaum Y, et al. Risk factors, angio-
graphic patterns and outcomes in patients with ventricular septal defect
complicating acute myocardial infarction. GUSTO-1 (Global Utiliza-
tion of Streptokinase and TPA for Occluded Coronary Arteries). Trial
Investigators. Circulation. 2000;101:27-32.
3. Labrousse L, Choukroun E, Chevalier JM, et al. Surgery for post-
infarction ventricular septal defect (VSD): risk factors for hospital
death and long term results. Euro J Cardiothorac Surg. 2002;21:
725-31.
4. Jeppsson A, Liden H, Johnsson P, Hartford M, Radegran K. Surgical
repair of post infarction ventricular septal defects: a national experience.
Euro J Cardiothorac Surg. 2005;27:216-21.
5. Pienvichit P, Piemonte TC. Percutaneous closure of postmyocardial
infarction ventricular septal defect with the CardioSEAL septal occluder
implant. Catheter Cardiovasc Interv. 2001;54:490-4.
Atypical presentation of extralobar sequestration with absence of
pericardium in an adult
Gourab Datta, MB, ChB, Jeymi Tambiah, MS, FRCS, Sheila Rankin, FRCR, Amanda Herbert, FRCPath,
and Loïc Lang-Lazdunski, MD, PhD, FRCS, London, United Kingdom
Extralobar sequestration (ELS) is a rare congenital lesionof the lung. We report a case of ELS with concurrentabsence of left pericardium presenting in an adult as ananterior mediastinal mass.
Clinical Summary
A 32-year-old man presented with a 3-week history of anterior
chest discomfort. He denied any weight loss, night sweats, or fever.
Clinical examination was unremarkable. Chest radiography and
computed tomography (CT) revealed a cystic mass in the left anterior
mediastinum (80  80  70 mm) in close proximity to the pul-
monary trunk (Figure 1). Tumor markers, including -fetoprotein,
-human chorionic gonadotropin, and lactate dehydrogenase, were
normal. A bronchogenic cyst or a thymic cyst was suspected. A
CT-guided biopsy was performed but was inconclusive. The pa-
tient was referred to our department for biopsy or excision of the
lesion.
We approached the mass through an anterior minithoracotomy
via the left second intercostal space. An initial noteworthy finding
was the absence of pericardium. A large cystic lesion with a
smooth grayish surface was visualized, and amorphous brownish
liquid was aspirated from it. Macroscopically, the lesion had the
appearance of a bronchogenic cyst and was adherent to the medi-
astinum and pulmonary hilum. The mass was dissected from
surrounding structures progressively by using diathermy and liga-
clips, but extraction resulted in massive bleeding. The incision was
enlarged, and a clamp was applied to the origin of the left pulmo-
nary artery (LPA). The bleeding source was identified as a small
vessel (2 mm) originating from the proximal LPA. It was con-
trolled with a single purse-string suture. The mass was completely
excised. The patient recovered uneventfully and was discharged on
day 5.
From the Department of Thoracic Surgery, Guy’s Hospital, London, United
Kingdom.
Received for publication April 1, 2006; revisions received April 3, 2006;
accepted for publication May 17, 2006.
Address for reprints: Loïc Lang-Lazdunski, MD, PhD, FRCS, Department
of Thoracic Surgery, Guy’s Hospital, St Thomas St, London SE1 9RT,
United Kingdom (E-mail: loic.lang-lazdunski@gstt.nhs.uk).
J Thorac Cardiovasc Surg 2006;132:1239-40
0022-5223/$32.00
Copyright © 2006 by The American Association for Thoracic Surgery
doi:10.1016/j.jtcvs.2006.05.054
Brief Communications
The Journal of Thoracic and Cardiovascular Surgery ● Volume 132, Number 5 1239


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Biventricular mechanical assist for complex, acute post-infarction ventricular septal defect

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